Outpatient Total Shoulder Arthroplasty Does Not Increase the 90-Day Risk of Complications Compared With Inpatient Surgery in Prescreened Patients

A Systematic Review of Patient Selection Criteria for Outpatient Total Shoulder Arthroplasty

The utilization of total shoulder arthroplasty (TSA) is increasing, driving associated annual health care costs higher. Opting for outpatient over inpatient TSA may provide a solution by reducing costs. However, there is no single set of accepted patient selection criteria for outpatient TSA. Here, the authors identify and systematically review 14 articles to propose evidence-based criteria that merit postoperative admission. Together, the studies suggest that patients with limited ability to abmluate independently or a history of congestive heart failure may benefit from postoperative at least one night of hospital based monitoring and treatment.

Racial and gender disparities in utilization of outpatient total shoulder arthroplasties

BACKGROUND

Utilization in outpatient total shoulder arthroplasties (TSAs) has increased significantly in recent years. It remains largely unknown whether utilization of outpatient TSA differs across gender and racial groups. This study aimed to quantify racial and gender disparities both nationally and by geographic regions.

METHODS

168,504 TSAs were identified using Medicare fee-for-service inpatient and outpatient claims data and beneficiary enrollment data from 2020 to 2022Q4. The percentage of outpatient cases, defined as cases discharged on the same day of surgery, was evaluated by racial and gender groups and by different census divisions. A multivariate logistics regression model controlling for patient sociodemographic information (White vs. non-White race, age, gender, and dual eligibility for both Medicare and Medicaid), hierarchical condition category (HCC) score, hospital characteristics, year fixed effects, and patient residency state fixed effects was performed.

RESULTS

The TSA volume per 1000 beneficiaries was 2.3 for the White population compared with 0.8, 0.6, and 0.3 for the Black, Hispanic, and Asian population, respectively. A higher percentage of outpatient TSAs were in White patients (25.6%) compared with Black patients (20.4%) (P < .001). The Black TSA patients were also younger, more likely to be female, more likely to be dually eligible for Medicaid, and had higher HCC risk scores. After controlling for patient sociodemographic characteristics and hospital characteristics, the odds of receiving outpatient TSAs were 30% less for Black than the White group (odds ratio 0.70). Variations were observed across different census divisions, with South Atlantic (0.67, P < .01), East North Central (0.56, P < .001), and Middle Atlantic (0.36, P < .01) being the 4 regions observed with significant racial disparities. Statistically significant gender disparities were also found nationally and across regions, with an overall odds ratio of 0.75 (P < .001).

DISCUSSION

Statistically significant racial and gender disparities were found nationally in outpatient TSAs, with Black patients having 30% (P < .001) fewer odds of receiving outpatient TSAs than White patients, and female patients with 25% (P < .001) fewer odds than male patients. Racial and gender disparities continue to be an issue for shoulder arthroplasties after the adoption of outpatient TSAs.

Outpatient vs. inpatient total shoulder arthroplasty: complication rates, clinical outcomes, and eligibility parameters

Background

Improvements in total shoulder arthroplasty (TSA), fast-track surgery, multimodal anesthesia, and rehabilitation protocols have opened up the possibility of outpatient care that is now routinely practiced at our European institution. The first objective of this study was to define the TSA outpatient population and to verify that outpatient management of TSA does not increase the risk of complications. The second objective was to determine patient eligibility parameters and the third was to compare functional outcomes and identify influencing factors.

Methods

The study included 165 patients who had primary TSA (106 outpatient and 59 inpatient procedures). The operative technique was the same for both groups. Demographics, complications, readmissions, and revisions were collected. American Society of Anesthesiologists, Constant, American Shoulder and Elbow Surgeons, University of California Los Angeles shoulder, and Shoulder Pain and Disability Index scores were obtained preoperatively and at 1.5, 6, and 12 months postoperatively. Satisfaction and visual analog scale pain scores also were documented. Statistical analysis was completed using multivariate linear regression.

Results

Outpatients were significantly younger and had lower American Society of Anesthesiologists scores than inpatients. The rates of complications, readmissions, and reoperations were not significantly different between groups. Outpatient surgery was not an independent risk factor for complications. At 1.5 months, better outcomes were noted in the outpatient group for all scores, and these reached statistical significance. Distance to home, dominant side, operative time, and blood loss were not associated with functional results. Multivariate analysis demonstrated that outpatient care was significantly associated with improved scores at 1.5 months and did not affect functional outcomes at 6 and 12 months.

Conclusion

This study reports the results of routine outpatient TSA within a European healthcare system. TSA performed in an outpatient setting was not an independent risk factor for complications and seemed to be an independent factor in improving early functional results.

Same-day discharge vs. inpatient total shoulder arthroplasty: an age stratified comparison of postoperative outcomes and hospital charges

BACKGROUND

As the number of total shoulder arthroplasty (TSA) procedures increases, there is a growing interest in improving patient outcomes, limiting costs, and optimizing efficiency. One approach has been to transition these surgeries to an outpatient setting. Therefore, the purpose of this study was to conduct an age-stratified analysis comparing the 90-day postoperative outcomes of primary TSA in the same-day discharge (SDD) and inpatient (IP) settings with a specific focus on the super-elderly.

METHODS

This retrospective study included all patients who underwent primary anatomic or reverse TSA between January 2018 and December 2021 in ambulatory and IP settings. The outcome measures included length of stay (LOS), complications, hospital charges, emergency department (ED utilization), readmissions, and reoperations within 90 days following TSA. Patients with LOS ≤8 hours were considered as SDD, and those with LOS >8 hours were considered as IP. P < .05 was considered statistically significant.

RESULTS

There were 121 and 174 procedures performed in SDD and IP settings, respectively. There were no differences in comorbidity indices between the SDD and IP groups (American Society of Anesthesiologists score P = .12, Elixhauser Comorbidity Index P = .067). The SDD cohort was younger than the IP group (SDD 67.0 years vs. 73.0 IP years, P < .001), and the SDD group higher rate of intraoperative tranexamic acid use (P = .015) and lower estimated blood loss (P = .009). There were no differences in 90-day overall minor (P = .20) and major complications (P = 1.00), ED utilization (P = .63), readmission (P = .25), or reoperation (P = .51) between the SDD and IP groups. When stratified by age, there were no differences in overall major (P = .80) and minor (P = .36) complications among the groups. However, the LOS was directly correlated with increasing age (LOS = 8.4 hours in ≥65 to <75-year cohort vs. LOS = 25.9 hours in ≥80-year cohort; P < .001). There were no differences in hospital charges between SDD and IP primary TSA in all 3 age groups (P = .82).

CONCLUSION

SDD TSA has a shorter LOS without increasing postoperative major and minor complications, ED encounters, readmissions, or reoperations. Older age was not associated with an increase in the complication profile or hospital charges even in the SDD setting, although it was associated with increased LOS in the IP group. These results suggest that TSA can be safely performed expeditiously in an outpatient setting.

Trends and outcomes of outpatient total shoulder arthroplasty after its removal from CMS's inpatient-only list

BACKGROUND

In January 2021, the US Medicare program approved reimbursement of outpatient total shoulder arthroplasties (TSA), including anatomic and reverse TSAs. It remains unclear whether shifting TSAs from the inpatient to outpatient setting has affected clinical outcomes. Herein, we describe the rate of outpatient TSA growth and compare inpatient and outpatient TSA complications, readmissions, and mortality.

METHODS

Medicare fee-for-service claims for 2019-2022Q1 were analyzed to identify the trends in outpatient TSAs and to compare 90-day postoperative complications, all-cause hospital readmissions, and mortality between outpatients and inpatients. Outpatient cases were defined as those discharged on the same day of the surgery. To reduce the COVID-19 pandemic's impact and selection bias, we excluded 2020Q2-Q4 data and used propensity scores to match 2021-2022Q1 outpatients with inpatients from the same period (the primary analysis) and from 2019-2020Q1 (the secondary analysis), respectively. We performed both propensity score-matched and -weighted multivariate analyses to compare outcomes between the two groups. Covariates included sociodemographics, preoperative diagnosis, comorbid conditions, the Hierarchical Condition Category risk score, prior year hospital/skilled nursing home admissions, annual surgeon volume, and hospital characteristics.

RESULTS

Nationally, the proportion of outpatient TSAs increased from 3% (619) in 2019Q1 to 22% (3456) in 2021Q1 and 38% (6778) in 2022Q1. A total of 55,166 cases were identified for the primary analysis (14,540 outpatients and 40,576 inpatients). Overall, glenohumeral osteoarthritis was the most common indication for surgery (70.8%), followed by rotator cuff pathology (14.6%). The unadjusted rates of complications (1.3 vs 2.4%, P < .001), readmissions (3.7 vs 6.1%, P < .001), and mortality (0.2 vs 0.4%, P = .024) were significantly lower among outpatient TSAs than inpatient TSAs. Using 1:1 nearest matching, 12,703 patient pairs were identified. Propensity score-matched multivariate analyses showed similar rates of postoperative complications, hospital readmissions, and mortality between outpatients and inpatients. Propensity score-weighted multivariate analyses resulted in similar conclusions. The secondary analysis showed a lower hospital readmission rate in outpatients (odds ratio: 0.8, P < .001).

CONCLUSIONS

There has been accelerated growth in outpatient TSAs since 2019. Outpatient and inpatient TSAs have similar rates of postoperative complication, hospital readmission, and mortality.

Outpatient Versus Inpatient Total Shoulder Arthroplasty: A Matched Cohort Analysis of Postoperative Complications, Surgical Outcomes, and Reimbursements

INTRODUCTION

There has been a trend toward performing arthroplasty in the ambulatory setting. The primary purpose of this study was to compare outpatient and inpatient total shoulder arthroplasties (TSAs) for postoperative medical complications, healthcare utilization outcomes, and surgical outcomes.

METHODS

Patients who underwent outpatient TSA or inpatient TSA with a minimum 5-year follow-up were identified in the PearlDiver database. These cohorts were propensity-matched based on age, sex, Charlson Comorbidity Index, smoking status, and obesity (body mass index > 30). All outcomes were analyzed using chi square and Student t-tests where appropriate.

RESULTS

Outpatient TSA patients had markedly lower rates of various 90-day medical complications. Outpatient TSA patients had lower risk of aseptic loosening at 2 years postoperation and lower risk of periprosthetic joint infection at 5 years postoperation relative to inpatient TSA patients. Outpatient TSA reimbursements were markedly lower than inpatient TSA reimbursements at the 30-day, 90-day, and 1-year postoperative intervals.

CONCLUSION

This study found patients undergoing outpatient TSA to be at lowers odds for both postoperative medical and surgical complications compared with those undergoing inpatient TSA. Despite increased risk of postoperative healthcare utilization for readmissions and emergency department visits, outpatient TSA was markedly less expensive at every postoperative time point assessed.

Introducing A Day-Case Shoulder Arthroplasty Pathway In The UK - How We Did It

Background

As the demand for elective orthopaedics grows, day-case arthroplasty is gaining popularity. The aim of this study was to create a safe and reproducible pathway for day-case shoulder arthroplasty (DCSA) based upon a literature review and discussion with the local multidisciplinary team (MDT).

Methods

A literature review was performed using OVID MEDLINE and Embase databases reporting 90-day complication and admission rates following DCSA. Minimum follow-up was 30 days. Day-case was defined as discharge on the same day of surgery.

Results

The literature review revealed a mean 90-day complication rate of 7.7% [range, 0-15.9%] and mean 90-day readmission rate of 2.5% [range 0-9.3%]. A pilot protocol was devised based upon the literature review and consisted of 5 phases: (1) pre-operative assessment, (2) intra-operative phase, (3) post-operative phase, (4) follow-up, and (5) readmission protocol. This was presented, discussed, amended, and ultimately ratified by the local MDT. In May 2021 the unit successfully completed its first day-case shoulder arthroplasty.

Discussion

This study proposes a safe and reproducible pathway for DCSA. Patient selection, well-defined protocols and communication within the MDT are important factors to achieve this. Further studies with extended follow-up will be needed to gauge long-term success within our unit.

Inpatient Versus Outpatient Surgery: A Comparison of Postoperative Mortality and Morbidity in Elective Operations

BACKGROUND

Operations performed outpatient offer several benefits. The prevalence of outpatient operations is growing. Consequently, the proportion of patients with multiple comorbidities undergoing outpatient surgery is increasing. We compared 30-day mortality and overall morbidity between outpatient and inpatient elective operations.

METHODS

Using the 2005-2018 ACS-NSQIP database, we evaluated trends in percent of hospital outpatient operations performed over time, and the percent of operations done outpatient versus inpatient by CPT code. Patient characteristics were compared for outpatient versus inpatient operations. We compared unadjusted and risk-adjusted 30-day mortality and morbidity for inpatient and outpatient operations.

RESULTS

A total of 6,494,298 patients were included. The proportion of outpatient operations increased over time, from 37.8% in 2005 to 48.2% in 2018. We analyzed the 50 most frequent operations performed outpatient versus inpatient 25-75% of the time (n = 1,743,097). Patients having outpatient operations were younger (51.6 vs 54.6 years), female (70.3% vs 67.3%), had fewer comorbidities, and lower ASA class (I-II, 69.3% vs. 59.9%). On both unadjusted and risk-adjusted analysis, 30-day mortality and overall morbidity were less likely in outpatient versus inpatient operations.

CONCLUSION

In this large multi-specialty analysis, we found that patients undergoing outpatient surgery had lower risk of 30-day morbidity and mortality than those undergoing the same inpatient operation. Patients having outpatient surgery were generally healthier, suggesting careful patient selection occurred even with increasing outpatient operation frequency. Patients and providers can feel reassured that outpatient operations are a safe, reasonable option for selected patients.

Wide Geographic Variation in Resource Utilization after Shoulder Arthroplasty

Background

There is growing interest in optimizing cost and resource utilization after shoulder arthroplasty, but little data to guide improvement efforts.

Objective

The purpose of this study was to evaluate geographic variation in length of stay and home discharge disposition after shoulder arthroplasty across the United States.

Methods

The Centers for Medicare and Medicaid Services database was used to identify Medicare discharges following shoulder arthroplasties performed from April 2019 through March 2020. National, regional (Northeast, Midwest, South, West), and state-level variation in length of stay and home discharge disposition rates were examined. The degree of variation was assessed using the coefficient of variation, with a value greater than 0.15 being considered as "substantial" variation. Geographic maps were created for visual representation of the data.

Results

There was substantial state-level variation in home discharge disposition rates (64% in Connecticut to 96% in West Virginia) and length of stay (1.01 days in Delaware to 1.86 days in Kansas). There was wide regional variation in length of stay (1.35 days in the West to 1.50 days in the Northeast) and home discharge disposition rates (73% in the Northeast to 85% in the West).

Conclusions

There is wide variation in resource utilization after shoulder arthroplasty across the United States. Certain patterns emerge from our data; for instance, the Northeast has the longest hospital stays with the lowest home discharge rates. This study provides important information for the implementation of targeted strategies to effectively reduce geographic variation in healthcare resource utilization.

Perioperative risk stratification tools for shoulder arthroplasty: a systematic review

BACKGROUND

Risk stratification tools are being increasingly utilized to guide patient selection for outpatient shoulder arthroplasty. The purpose of this study was to identify the existing calculators used to predict discharge disposition, postoperative complications, hospital readmissions, and patient candidacy for outpatient shoulder arthroplasty and to compare the specific components used to generate their prediction models.

METHODS

This review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis protocol. PubMed, Cochrane Library, Scopus, and OVID Medline were searched for studies that developed calculators used to determine patient candidacy for outpatient surgery or predict discharge disposition, the risk of postoperative complications, and hospital readmissions after anatomic or reverse total shoulder arthroplasty (TSA). Reviews, case reports, letters to the editor, and studies including hemiarthroplasty cases were excluded. Data extracted included authors, year of publication, study design, patient population, sample size, input variables, comorbidities, method of validation, and intended purpose. The pros and cons of each calculator as reported by the respective authors were evaluated.

RESULTS

Eleven publications met inclusion criteria. Three tools assessed patient candidacy for outpatient TSA, 3 tools evaluated the risk of 30- or 90-day hospital readmission and postoperative complications, and 5 tools predicted discharge destination. Four calculators validated previously constructed comorbidity indices used as risk predictors after shoulder arthroplasty, including the Charlson Comorbidity Index, Elixhauser Comorbidity Index, modified Frailty Index, and the Outpatient Arthroplasty Risk Assessment, while 7 developed newcalculators. Nine studies utilized multiple logistic regression to develop their calculators, while 1 study developed their algorithm based on previous literature and 1 used univariate analysis. Five tools were built using data from a single institution, 2 using data pooled from 2 institutions, and 4 from large national databases. All studies used preoperative data points in their algorithms with one tool additionally using intraoperative data points. The number of inputs ranged from 5 to 57 items. Four calculators assessed psychological comorbidities, 3 included inputs for substance use, and 1 calculator accounted for race.

CONCLUSION

The variation in perioperative risk calculators after TSA highlights the need for standardization and external validation of the existing tools. As the use of outpatient shoulder arthroplasty increases, these calculators may become outdated or require revision. Incorporation of socioeconomic and psychological measures into these calculators should be investigated.

Outpatient shoulder arthroplasty in the COVID-19 era: 90-day complications and risk factors

BACKGROUND

With the COVID-19 pandemic placing an increased burden on health care systems, shoulder arthroplasties are more commonly being performed as outpatient procedures. The purpose of this study was to characterize the 90-day episode-of-care complications of consecutive shoulder arthroplasties defaulted for outpatient surgery without using a prior algorithm for patient selection and to assess for their risk factors. We hypothesized that outpatient shoulder arthroplasty would be a safe procedure for all patients, regardless of patient demographics and comorbidities.

METHODS

A retrospective review of consecutive patients who underwent planned outpatient anatomic or reverse total shoulder arthroplasty between March 2020 and January 2022 with 3-month follow-up was performed. All patients were scheduled for outpatient surgery regardless of medical comorbidities. Patient demographics; pre/postoperative patient-reported outcomes including visual analog scale, subjective shoulder value, and American Shoulder and Elbow Surgeons score; pre/postoperative range of motion; and complications were collected from medical chart review. Multivariate logistic regression was used to identify predictors of the following outcomes: 1. Unplanned overnight hospital stay, 2. 90-day unplanned emergency department (ED)/clinic visit, 3. 90-day hospital readmission, 4. 90-day complications requiring revision.

RESULTS

One hundred twenty-seven patients (47% male, 17% tobacco users, 18% diabetics) with a mean age 69 ± 9 years were identified, of whom 92 underwent reverse total shoulder arthroplasty and 35 underwent anatomic total shoulder arthroplasty. All patient-reported outcomes and range of motion were significantly improved at 3 months. There were 15 unplanned overnight hospital stays (11.8%) after the procedure. Within 90 days postoperatively, there were 17 unplanned ED/clinic visits (13.4%), 7 hospital readmissions (5.5%), and 4 complications requiring revision (3.1%). Factors predictive of unplanned overnight stay included age above 70 years (odds ratio [OR], 36.80 [95% confidence interval [CI], 2.20-615.49]; P = .012), tobacco use (OR, 12.90 [95% CI, 1.23-135.31]; P = .033), and American Society of Anesthesiologists status of 3 (OR, 13.84 [95% CI, 1.22-156.57]; P = .034). The only factor predictive of unplanned ED/clinic visit was age over 70 years old (OR, 7.52 [95% CI, 1.26-45.45]; P = .027). No factors were predictive of 90-day hospital readmission or revision.

CONCLUSION

Outpatient shoulder arthroplasty is a safe procedure with excellent outcomes and low rates of readmissions and can be considered as the default plan for all patient undergoing shoulder arthroplasty. Patients who are above 70 years of age, use tobacco, and have ASA score of 3, however, may be less suitable for outpatient arthroplasty and should be counseled regarding the higher risk of unplanned overnight hospitalization.

A systematic review of clinical outcomes for outpatient vs. inpatient shoulder arthroplasty

BACKGROUND

Outpatient shoulder arthroplasty is growing in popularity as a cost-effective and potentially equally safe alternative to inpatient arthroplasty. The aim of this study was to investigate literature relating to outpatient shoulder arthroplasty, looking at clinical outcomes, complications, readmission, and cost compared to inpatient arthroplasty.

METHODS

We conducted a systematic review of Medline, Embase and Cochrane Library databases from inception to 6 April 2020. Methodological quality was assessed using MINORS and GRADE criteria.

RESULTS

We included 17 studies, with 11 included in meta-analyses and 6 in narrative review. A meta-analysis of hospital readmissions demonstrated no statistically significant difference between outpatient and inpatient cohorts (OR = 0.89, p = 0.49). Pooled post-operative complications identified decreased complications in those undergoing outpatient surgery (OR = 0.70, p = 0.02). Considerable cost saving of between $3614 and $53,202 (19.7-69.9%) per patient were present in the outpatient setting. Overall study quality was low and presented a serious risk of bias.

DISCUSSION

Shoulder arthroplasty in the outpatient setting appears to be as safe as shoulder arthroplasty in the inpatient setting, with a significant reduction in cost. However, this is based on low quality evidence and high risk of bias suggests further research is needed to substantiate these findings.

Current Status Regarding the Safety of Inpatient Versus Outpatient Total Shoulder Arthroplasty: A Systematic Review

BACKGROUND

Surgeons have begun to transition total shoulder arthroplasty (TSA) to the outpatient setting in order to contain costs and reallocate resources.

PURPOSE

The purpose of this systematic review was to evaluate the safety and cost of outpatient TSA by assessing associated complication rates, clinical outcomes, and total treatment charges.

METHODS

The MEDLINE, Embase, and Cochrane Library online databases were queried in March 2020 for studies on outpatient shoulder arthroplasty. Inclusion criteria were (1) a study population undergoing TSA, (2) discharge on the day of surgery, and (3) inclusion of at least 1 reported outcome.

RESULTS

Of 20 studies identified that met inclusion criteria, 14 were comparative studies involving an inpatient control group, 2 of which were matched by age and comorbidities. The remaining studies used control groups consisting of inpatient TSAs who were older or more medically infirm according to American Society of Anesthesiologists (ASA) or Charlson Comorbidity Index (CCI) scores. The combined average age of the outpatient and inpatient groups was 66.5 and 70.1 years, respectively. Patients who underwent outpatient TSA had similar rates of readmissions, emergency department visits, and perioperative complications in comparison to inpatients. Patients also reported comparably high levels of satisfaction with outpatient procedures. Four economic analyses demonstrated substantial cost savings with outpatient TSA in comparison to inpatient surgery.

CONCLUSION

In carefully selected patients, outpatient TSA appears to be equally safe but less resource intensive than inpatient arthroplasty. Nonetheless, there remains a need for larger prospective studies to decisively characterize the relative safety of outpatient TSA among patients with similar baseline health.

A Risk Stratification Nomogram to Predict Inpatient Admissions After Total Shoulder Arthroplasty Among Patients Eligible for Medicare

The goal of this study was to establish a risk stratification nomogram to aid in determining the need for inpatient admission among patients who were eligible for Medicare and were undergoing primary total shoulder arthroplasty (TSA). The American College of Surgeons National Surgical Quality Improvement Program database was queried to identify all patients older than 65 years who underwent primary TSA between 2006 and 2016. The primary outcome measure was inpatient admission, as defined by hospital length of stay longer than 2 days. Multiple demographic, comorbid, and peri-operative variables were used in a multivariate logistic regression model to yield a risk stratification nomogram. A total of 1514 inpatient and 6020 out-patient admissions were analyzed. Age older than 80 years (odds ratio [OR], 2.69; P<.0001; 95% CI, 2.21-3.27), female sex (OR, 2.18; P<.0001; 95% CI, 1.90-2.51), dependent functional status (OR, 1.69; P<.0001; 95% CI, 1.2-2.38), dialysis (OR, 3.48; P=.029; 95% CI, 1.14-10.63), admission from an inpatient facility (OR, 1.76; P<.0001; 95% CI, 1.70-1.82), and inflammatory arthritis (OR, 1.69; P<.02; 95% CI, 1.25-13.78) were the greatest determinants of inpatient stay. The resulting predictive model showed acceptable discrimination and calibration. Our model enabled reliable and straightforward identification of the most suitable candidates for inpatient admission among patients who were eligible for Medicare and were undergoing primary TSA. Patients who were receiving dialysis, who had dyspnea at rest, and who had bleeding disorders were more likely to be admitted as inpatients after TSA. Larger multicenter studies are necessary to externally validate the proposed predictive nomogram. [Orthopedics. 2022;45(1):43-49.].

Safety and Cost Effectiveness of Outpatient Total Shoulder Arthroplasty: A Systematic Review

INTRODUCTION

Changes in healthcare policy have driven many hospital-based surgeries to the outpatient environment. Multiple studies have shown outpatient total shoulder arthroplasty (TSA) is a safe alternative to the inpatient setting. This systematic review evaluates patient selection, perioperative protocols, complications, costs, patient satisfaction, and clinical outcomes of outpatient TSA and compares these with their inpatient counterparts.

METHODS

The Emnbase, Medline, and CENTRAL databases were queried on April 30, 2020, for outpatient TSA studies, identifying 232 articles, with 21 meeting inclusion criteria. This involved 25,808 and 231,408 patients undergoing outpatient and inpatient TSA, respectively. Failed same-day discharge, readmissions, revision surgeries, cost, and complications among outpatient TSA were aggregated when raw numbers were available. Statistical significance for comparisons among outpatient and inpatient TSA within individual studies was alpha = 0.05.

RESULTS

Ten studies evaluated same-day discharge rate, with 440 of 446 patients (98.7%) meeting the goals. Fourteen studies evaluated readmissions, revision surgeries, and complications, with readmissions in 238 of 6,133 patients (3.9%), revision surgeries in 32 of 1,484 patients (2.1%), and complications in 376 of 4,977 patients (7.6%). Readmission rates were similar between inpatients and outpatients, with only one study finding more readmissions after inpatient TSA. Complications were more common in inpatient TSA in five studies. Outpatient TSA demonstrated a charge reduction of $25,509 to $53,202 per patient, and patient satisfaction after outpatient TSA was "good to excellent" in more than 95% of patients. Patient selection for outpatient TSA used patient age, medical comorbidities, social support, living proximity to location of surgery, and lack of preoperative opioid use.

DISCUSSION

Outpatient TSA in appropriately selected patients is a safe and cost-effective alternative to inpatient TSA. However, the literature is limited to national database or small retrospective studies. Large prospective, cohort studies are necessary to further assess differences in complication profiles between outpatient and inpatient TSA.

LEVEL OF EVIDENCE

Level IV; systematic review.

Outpatient Shoulder Arthroplasty-A Systematic Review

Objective

Recent reports have shown that outpatient shoulder arthroplasty (SA) may be a safe alternative to inpatient management in appropriately selected patients. The purpose was to review the literature reporting on outpatient SA.

Methods

A systematic review of publications on outpatient SA was performed. Included publications discussed patients who were discharged on the same calendar day or within 23 hours from surgery. Articles were categorized by discussions on complications, readmissions, and safety, patient selection, pain management strategies, cost effectiveness, and patient and surgeon satisfaction.

Results

Twenty-six articles were included. Patients undergoing outpatient SA were younger and with a lower BMI than those undergoing inpatient SA. Larger database studies reported more medical complications for patients undergoing inpatient compared to outpatient SA. Articles on pain management strategies discussed both single shot and continuous interscalene blocks with similar outcomes. Both patients and surgeons reported high levels of satisfaction following outpatient SA, and cost analysis studies demonstrated significant cost savings for outpatient SA.

Conclusion

In appropriately selected patients, outpatient SA can be a safe, cost-saving alternative to inpatient care and may lead to high satisfaction of both patients and physicians, though further studies are needed to clarify appropriate utilization of outpatient SA.

Comparison of outpatient vs. inpatient anatomic total shoulder arthroplasty: a propensity score–matched analysis of 20,035 procedures

Background

As the proportion of anatomic total shoulder arthroplasty (aTSA) operations performed at outpatient surgical sites continues to increase, it is important to evaluate the clinical implications of this evolution in care.

Methods

Patients who underwent TSA for glenohumeral osteoarthritis from 2007 to 2019 were identified in the American College of Surgeons National Surgical Quality Improvement Program registry. Demographic data and 30-day outcomes were collected, and patients were separated into inpatient and outpatient (defined as same day discharge) groups. To control for confounding variables, a propensity score–matching algorithm was utilized. Outcomes included 30-day adverse events, readmission, and operative time.

Results

A total of 20,035 patients who underwent aTSA between 2007 and 2019 were identified: 18,707 inpatient aTSAs and 1328 outpatient aTSAs. On matching, there were no significant differences in patient characteristics between inpatient and outpatient cohorts. Patients who underwent outpatient aTSA were less likely to experience a serious adverse event when compared with their matched inpatient aTSA counterparts (outpatient: 1.1% vs. inpatient: 2.1%, P = .03). Outpatient aTSA was associated with similar rates of all specific individual complications and readmissions (1.5% vs. 1.9%, P = .31).

Conclusion

When compared with a propensity score–matched cohort of inpatient counterparts, the present study found outpatient aTSA was associated with significantly reduced severe adverse events and similar readmission rates. These findings support the growing use of outpatient aTSA in appropriately selected patients.

Day case versus inpatient total shoulder arthroplasty: A systematic review and meta-analysis

BACKGROUND

A number of papers have been published comparing the safety and efficacy of day case and inpatient anatomic or reverse total shoulder arthroplasty. However, no systematic review of the literature has been published to date. The aim of this review was to determine if day case total shoulder arthroplasty (length of stay <24 h) leads to similar outcomes as standard-stay inpatients (length of stay ≥24 h).

METHODS

The US National Library of Medicine (PubMed/MEDLINE), EMBASE, and the Cochrane Database of Systematic Reviewers were queried for publications utilizing keywords that were pertinent to total shoulder arthroplasty, day case, outpatient and inpatient, clinical or functional outcomes, and complications. In order to determine the quantitative impact of day case total shoulder arthroplasty on readmission and revision rate, a meta-analysis was performed on articles that observed 30- or 90-day readmission or revision.

RESULTS

Eight articles were found to be suitable for inclusion in the present study which included 6103 day case total shoulder arthroplasty and 147,463 inpatient total shoulder arthroplasty. Following meta-analysis, there was no significant difference among patients who underwent day case total shoulder arthroplasty compared to inpatient total shoulder arthroplasty regarding revision rates (OR: 1.001; 95% CI: 0.721-1.389; p = 0.995) and 30-day readmission rates (OR: 0.940; 95% CI: 0.723-1.223; p = 0.646). In contrast, patients who underwent day case total shoulder arthroplasty were less likely to have a readmission within 90 days compared to their inpatient counterparts (OR: 0.839; 95% CI: 0.704-0.999; p = 0.049). Two out of eight studies reported comparable baseline clinical characteristics among groups, while five studies reported significant differences and one study did not provide information regarding clinical characteristics, such as medical comorbidities or American Society of Anaesthesiologists'(ASA) score. No significant difference among groups was found in all or almost all studies regarding mortality rates, and rates of cardiac complications, cerebrovascular events, thromboembolic events, pulmonary complications, cardiac complications, and nerve complications. Finally, results were rather conflicting regarding the correlation of day case total shoulder arthroplasty to the rate of surgical site infections.

CONCLUSIONS

This study showed that day case total shoulder arthroplasty might lead to similar rates of mortality, complications, revisions, and readmissions compared to inpatient total shoulder arthroplasty when used in a selected population of younger, healthier, and more male patients. In contrast, there was no consensus regarding the impact of day case total shoulder arthroplasty on the rate of surgical site infections. Finally, further research of higher quality is required to establish patient demographic criteria, ASA score, or comorbidity index cut off that might be used to define day case-treated patients who seem to have equivalent outcomes compared to inpatient-treated patients.Level of evidence: Systematic review of level III studies (lowest level included).

Is outpatient shoulder arthroplasty safe in patients aged ≥65 years? A comparison of readmissions and complications in inpatient and outpatient settings

BACKGROUND

Recent studies indicate that outpatient total shoulder arthroplasty (TSA) is cost-effective and may have a low complication rate similar to inpatient TSA. However, existing studies have included younger patient cohorts who typically possess fewer medical comorbidities. Patients aged ≥65 years are commonly enrolled in Medicare, which has traditionally designated TSA as an inpatient-only procedure. The purpose of this study was to compare surgical complication rates and 90-day readmission rates between inpatient and outpatient TSA performed in adults aged ≥65 years.

METHODS

Medical records for all patients aged ≥65 years who underwent primary anatomic or reverse TSA by a single surgeon from July 2015 to May 2020 were reviewed. Patients were preselected for outpatient or inpatient surgery based on lack of significant cardiopulmonary comorbidities and patient preference. Demographics, body mass index (BMI), and American Society of Anesthesiologists (ASA) scores were collected in addition to emergency department (ED) visits and readmissions within 90 days of the index surgery. Relationships among frequency and types of complications and surgical setting (inpatients vs. outpatient) were assessed. Complication rates and demographic variables between inpatient and outpatient procedures were compared. Logistic regressions were performed to account for interacting predictor variables on the odds of having complications.

RESULTS

A total of 145 shoulders (138 patients; 95 male, 43 female) were included in the analysis, of which 98 received inpatient TSA and 47 received outpatient TSA. Average age was 75.5 ± 7.2 for inpatient TSA and 70.5 ± 4.5 for outpatient TSA (P < .001). Patient age (P < .001), ASA score ≥3 (P < .001), and reverse TSA (P = .002) were significantly positively correlated with receiving inpatient surgery. There were 16 complications (16.3%) in the inpatient group and 9 complications (19.1%) in the outpatient group (P = .648). There were no significant differences in the frequency of postoperative complications, return to the ED, or reoperations between inpatient and outpatient procedures (P > .05). Each 1-year increase in age increased the predicted odds of having a surgical complication by 14% (odds ratio = 1.14; P = .021), irrespective of surgical setting. Those who underwent inpatient TSA had a significantly higher frequency of 90-day readmission (inpatient=16, outpatient=1; P = .034).

CONCLUSIONS

Postoperative complications and ED returns were not significantly different between inpatient and outpatient TSA. Each 1-year increase in age increased the odds of postoperative surgical complications by 14%, regardless of surgical setting. Outpatient TSA was found to be safe for appropriately selected patients aged ≥65 years, and re-evaluation of TSA as an inpatient-only procedure should be considered.

Utilization of a Standardized Care Pathway to Decrease Costs of Ankle Fracture Management

INTRODUCTION

Ankle fractures are the most common fracture of the foot and ankle treated at trauma hospitals in the United States, costing millions of dollars yearly. The purpose of this study was to determine whether a standardized care pathway led to a difference in the direct and indirect costs of surgical fixation of ankle fractures at one Level I Trauma Center and tertiary care medical center.

METHODS

We analyzed cost, volume, length of stay, and collections for surgical treatment of ankle fractures in inpatient and outpatient settings by the orthopaedics and podiatry departments during fiscal years 2016 to 2018. Based on these data, we compared projected costs and collections across a 5-year period with the procedure being done by a single department (orthopaedics only and podiatry only).

RESULTS

Total costs per case fell by 18% in the orthopaedics department and 8% in the podiatry department over the 3-year period. The podiatry department spent an average of $1,296 (46%) more per case than the orthopaedics department, driven by increased average supply costs. Both departments had significantly decreased direct costs (P = 0.0039 orthopaedics and P = 0.033 podiatry) in the outpatient setting. The orthopaedics department also had significantly lower average supply costs than the podiatry department (P = 0.045) and significantly decreased total costs in the outpatient setting (P = 0.0084).

DISCUSSION

The orthopaedics department performed a higher volume of cases at a lower cost per case than the podiatry department. These savings were driven by a standardized ankle fracture treatment pathway that we propose decreased direct and supply costs. Our results suggest that surgical treatment of ankle fracture cases using a standardized care pathway is economically advantageous because of limiting variations in care and creating manageable workflows.

Is outpatient shoulder arthroplasty safe? A systematic review and meta-analysis

BACKGROUND

Amid rising health care costs and recent advances in surgical and anesthetic protocols, the rate of outpatient joint arthroplasty has risen steadily in recent years. Although the safety of outpatient total knee arthroplasty and total hip arthroplasty has been well established, outpatient shoulder arthroplasty is still in its infancy. The purpose of this study was to synthesize the current literature and provide further data regarding the outcomes and safety of outpatient shoulder arthroplasty.

METHODS

A systematic review was conducted following the standard PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Included were studies that evaluated the outcomes of patients undergoing outpatient total shoulder arthroplasty (TSA) or reverse TSA. Meta-analysis was conducted using Mantel-Haenszel statistics to generate odds ratios (ORs) and their corresponding 95% confidence intervals (CIs) comparing outpatient and inpatient shoulder arthroplasty.

RESULTS

Twelve studies were included, with a total of 194,513 patients, of whom 7162 were outpatients. Of the studies, 8 were level III and 4 were level IV. The average age of the outpatients was 66.6 years, and the average age of the inpatients was 70.1 years. The overall OR for complications was significantly lower in outpatients (OR, 0.40; 95% CI, 0.35-0.45) than in inpatients. There was no significant difference in rates of 90-day readmission (OR, 0.88; 95% CI, 0.75-1.03), revision (OR, 0.96; 95% CI, 0.65-1.41), and infection (OR, 0.93; 95% CI, 0.64-1.35) when comparing outpatients with inpatients.

CONCLUSION

Outpatient TSA, in an appropriately selected patient population, is safe and results in comparable patient outcomes to those of inpatient shoulder arthroplasty. Given the expected increase in the number of patients requiring TSA, surgeons, hospital administrators, and insurance carriers should strongly consider the merits of a cost- and care-efficient approach to total shoulder replacement.

Determining the validity of the Outpatient Arthroplasty Risk Assessment (OARA) tool for identifying patients for safe same-day discharge after primary shoulder arthroplasty

BACKGROUND

Early discharge has been a target of cost-control efforts given the growing demand for joint replacement surgery. The Outpatient Arthroplasty Risk Assessment (OARA) score, a medically based risk-assessment score, has shown high predictive ability in achieving safe early discharge following outpatient lower-extremity arthroplasty using a score threshold initially set at ≤59 points but more recently adapted to ≤79 points. However, no study has been performed using the OARA tool for shoulder replacement, which has been shown to have lower associated medical risks than lower-extremity arthroplasty. The purpose of this study was to determine the OARA score threshold for same-day discharge (SDD) following shoulder arthroplasty and evaluate its effectiveness in selecting patients for SDD. We hypothesized that the OARA score threshold for shoulder arthroplasty would be higher than that for lower-extremity arthroplasty.

METHODS

We performed a retrospective review of 422 patients who underwent primary anatomic or reverse shoulder arthroplasty between April 2018 and October 2019 performed by a single surgeon. As standard practice, all patients were counseled preoperatively regarding SDD and given the choice to stay overnight. Medical history, length of stay, and 90-day readmissions were obtained from medical records. Analysis of variance testing and screening test characteristics compared the performance of the OARA score vs. the American Society of Anesthesiologists Physical Status (ASA-PS) class and a previously published OARA score threshold used to define a low risk of outpatient lower-extremity arthroplasty.

RESULTS

A preoperative OARA score cutoff of ≤110 points demonstrated a sensitivity of 98.0% for identifying patients with SDD after shoulder arthroplasty, compared with 66.7% using the hip and knee OARA score threshold of ≤59 points (P < .0001) and 80.4% using ASA-PS class ≤ 2 (P = .008). OARA scores ≤ 110 points also showed a negative predictive value of 98.9% and a false-negative rate of 2.0% but remained incomprehensive with a specificity of 24.0% (P < .0001). Analysis of variance demonstrated that mean OARA scores increased significantly with length of stay (P = .001) compared with ASA-PS classes (P = .82). Patients with OARA scores ≤ 110 points were also 2.5 times less likely to have 90-day emergency department visits (P = .04) than those with OARA scores > 110 points. There was no difference in 30- and 90-day readmission rates for patients with OARA scores ≤ 59 points, OARA scores ≤ 110 points, and ASA-PS classes ≤ 2.

CONCLUSION

Our study suggests that a preoperative OARA score threshold of ≤110 points is effective and conservative in screening patients for SDD following shoulder arthroplasty, with low rates of 90-day emergency department visits and readmissions. This threshold is a useful screening tool to identify patients who are not good candidates for SDD.

Complication rates and outcomes after outpatient shoulder arthroplasty: a systematic review

Background

As the number of total shoulder arthroplasties (TSAs) performed annually increases, some surgeons have begun to shift toward performing TSAs in the outpatient setting. However, it is imperative to establish the safety of outpatient TSA. The purpose of this systematic review was to define complication, readmission, and reoperation rates and patient-reported outcomes after outpatient TSA.

Methods

A systematic review of the literature was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using three databases (PubMed, Ovid, and Embase). English-language publications describing results on complication rates in patients who underwent TSA in an outpatient or ambulatory setting were included. All nonclinical and deidentified database studies were excluded. Bias assessment was conducted with the methodologic index for nonrandomized studies criteria.

Results

Seven studies describing outcomes in outpatient TSA were identified for inclusion. The included studies used varying criteria for selecting patients for an outpatient procedure. The total outpatient 90-day complication rate (commonly including hematomas, wound issues, and nerve palsies) ranged from 7.1%-11.5%. Readmission rates ranged from 0%-3.7%, and emergency and urgent care visits ranged from 2.4%-16.1%. Patient-reported outcomes improved significantly after outpatient TSA in all studies. Two studies found a higher complication rate in the comparative inpatient cohort (P = .023-.027). Methodologic index for nonrandomized studies scores ranged from 9 to 11 (of 16) for noncomparative studies (n = 3), while all comparative studies received a score of a 16 (of 24).

Conclusion

Outpatient TSA in properly selected patients results in a similar complication rate to inpatient TSA. Further studies are needed to aid in determining proper risk stratification to direct patients to inpatient or outpatient shoulder arthroplasty.

Outpatient Total Shoulder Arthroplasty: A Systematic Review Evaluating Outcomes and Cost-Effectiveness

BACKGROUND

Orthopaedic surgical procedures are increasingly being performed in outpatient settings. The drive for cost reduction without compromising patient safety and outcomes has increased interest in outpatient total shoulder arthroplasty (TSA). The primary aim of this study was to perform a review of the evidence regarding the outcomes and cost-effectiveness of outpatient TSA.

METHODS

A search of the PubMed, Embase, and Cochrane Library databases was performed using several keywords: "outpatient," "shoulder replacement," "ambulatory," "day case," "day-case," "shoulder arthroplasty," "same day," and "shoulder surgery." Studies that were published from May 2010 to May 2020 in the English language were considered. Research design, questions, and outcomes were recorded for each study. Qualitative and quantitative pooled analysis was performed on the data where appropriate.

RESULTS

Twenty studies met the inclusion criteria. Six retrospective studies compared complication rates between inpatient and outpatient cohorts and found no significant differences. Four studies found that the complication rate was lower in the outpatient cohort compared with the inpatient cohort. In a pooled analysis, the readmission rate after outpatient TSA was significantly lower than the readmission rate after inpatient TSA at 30 days (0.65% vs. 0.95%) and 90 days (2.03% vs. 2.87%) postoperatively (p < 0.05 for both). Four studies evaluated the cost of outpatient TSA in comparison with inpatient TSA. All of these studies found that TSA at an ambulatory surgery center was significantly less costly than TSA at an inpatient facility, both for the health-care system and for the patient. Patient selection for outpatient TSA may depend on several important factors, including the presence or absence of diabetes, chronic obstructive pulmonary disease, chronic kidney disease, congestive heart failure, poor functional status, higher American Society of Anesthesiologists class, chronic narcotic use, higher body mass index, and older age.

CONCLUSIONS

Our results show that patient selection is the most critical factor that predicts the success of outpatient TSA. While outpatient TSA is significantly less costly than inpatient TSA, patients undergoing outpatient TSA are more likely to be healthier than patients undergoing inpatient TSA. More high-quality long-term studies are needed to add to this body of evidence.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Outcomes of Same-Day Orthopedic Surgery: Are Spine Patients More Likely to Have Optimal Immediate Recovery From Outpatient Procedures?

BACKGROUND

Spinal surgery is associated with an inherently elevated risk profile, and thus far there has been limited discussion about how these outpatient spine patients are benefiting from these same-day procedures against other typical outpatient orthopedic surgeries.

METHODS

Orthopedic patients who received either inpatient or outpatient surgery were isolated in the American College of Surgeons National Surgical Quality of Improvement Program (2005-2016). Patients were stratified by type of orthopedic surgery received (spine, knee, ankle, shoulder, or hip). Mean comparisons and chi-squared tests assessed basic demographics. Perioperative complications were analyzed via regression analyses in regard to their principal inpatient or outpatient orthopedic surgery received.

RESULTS

This study included 729 480 surgical patients: 32.5% received spinal surgery, 36.5% knee, 24.1% hip, 4.9% shoulder, and 1.7%ankle. Of those who received a spinal procedure, 74.7% were inpatients (IN), and 25.3% were outpatients (OUT): knee: 96.1% IN, 3.9% OUT; hip:98.9% IN, 1.1% OUT; ankle: 29% IN, 71% OUT; and shoulder: 52.6% IN, 47.6% OUT. Hip patients were the oldest, and knee patients had the highest body mass index out of the orthopedic groups (P < .00). Spine IN patients experienced more complications than the other orthopedic groups and had the lowest OUT complications(both P < .05). This same trend of having higher IN complications than OUT complications was identified for hip, shoulder, and knee. However, ankle procedures had greater OUT procedure complications than IN (P < .05). After controlling for age, body mass index, and Charlson Comorbidity Index, IN procedures, such as knee, hip, spine, and shoulder, were significantly associated with experiencing postoperative complications. From 2006 to 2016, IN and OUT surgeries were significantly different among complications experienced for all of the orthopedic groups (P < .05) with complications decreasing for IN and OUT patients by 2016.

CONCLUSIONS

Over the past decade, spine surgery has decreased in complications for IN and OUT procedures along with IN/OUT knee, ankle, hip, and shoulder procedures, reflecting greater tolerance for risk in an outpatient setting.

LEVEL OF EVIDENCE

3.

CLINICAL RELEVANCE

Despite the increase in riskier spine procedures, complications have decreased over the years. Surgeons should aim to continue to decrease inpatient spine complications to the level of other orthopedic surgeries.

The effect of a statewide COVID-19 shelter-in-place order on shoulder arthroplasty for proximal humerus fracture volume and length of stay

Background

Although the COVID-19 pandemic has disrupted elective shoulder arthroplasty throughput, traumatic shoulder arthroplasty procedures are less apt to be postponed. We sought to evaluate shoulder arthroplasty utilization for fracture during the COVID-19 pandemic and California's associated shelter-in-place order compared to historical controls.

Methods

We conducted a cohort study with historical controls, identifying patients who underwent shoulder arthroplasty for proximal humerus fracture in California using our integrated electronic health record. The time period of interest was following the implementation of the statewide shelter-in-place order: March 19, 2020-May 31, 2020. This was compared to three historical periods: January 1, 2020-March 18, 2020, March 18, 2019-May 31, 2019, and January 1, 2019-March 18, 2019. Procedure volume, patient characteristics, in-hospital length of stay, and 30-day events (emergency department visit, readmission, infection, pneumonia, and death) were reported. Changes over time were analyzed using linear regression adjusted for usual seasonal and yearly changes and age, sex, comorbidities, and postadmission factors.

Results

Surgical volume dropped from an average of 4.4, 5.2, and 2.6 surgeries per week in the historical time periods, respectively, to 2.4 surgeries per week after shelter-in-place. While no more than 30% of all shoulder arthroplasty procedures performed during any given week were for fracture during the historical time periods, arthroplasties performed for fracture was the overwhelming primary indication immediately after the shelter-in-place order. More patients were discharged the day of surgery (+33.2%, P = .019) after the shelter-in-place order, but we did not observe a change in any of the corresponding 30-day events.

Conclusions

The volume of shoulder arthroplasty for fracture dropped during the time of COVID-19. The reduction in volume could be due to less shoulder trauma due to shelter-in-place or a change in the indications for arthroplasty given the perceived higher risks associated with intubation and surgical care. We noted more patients undergoing shoulder arthroplasty for fracture were safely discharged on the day of surgery, suggesting this may be a safe practice that can be adopted moving forward.

Level of Evidence

Level III; Retrospective Case-control Comparative Study

A Geographic Population-level Analysis of Access to Total Shoulder Arthroplasty in the State of Texas

INTRODUCTION

Managing costs and improving access to care are two important goals of healthcare policy. The purposes of this study were to (1) evaluate the changes in distribution of total shoulder arthroplasty (TSA) cases in the state of Texas from 2010 to 2015 and (2) to evaluate patient access to TSA surgery centers as measured by driving miles.

METHODS

Inpatient (IP) and outpatient (OP) records were obtained from 2010 to 2015 from the Texas Department of State Health Services. All primary elective anatomic or reverse TSAs for patients with Texas-based home residence zip codes were included. Driving miles between patient zip codes and their chosen TSA surgery centers were estimated, and the results were compared between IP (high-volume [HV-IP] or low-volume [LV-IP]) and OP centers. Paired student t-tests, multivariate regressions, and mixed-model analysis of variance (ANOVA) were performed for volume comparisons, interactions between TSA centers types, and yearly trend data, respectively.

RESULTS

Between 2010 and 2015, a total of 21,092 TSA procedures were performed across 321 surgery centers in the state of Texas (19,629 IP [93.1%] and 1,463 OP [6.9%]). During this time, the cumulative volume of IP TSA per 100,000 Texas residents increased by 109.1%, whereas the cumulative volume of OP TSA increased by 143.7%. Approximately 85.5% of included patients resided within 50 miles of any TSA surgery center; however, only 47.0% of the total Texas population resided within 50 miles of any TSA surgery center. This relationship remained true at every time point irrespective of their volume designations (OP, IP, HV-IP, and LV-IP).

CONCLUSION

Despite the overall increase in TSA volume over time, the majority all TSA utilization in the state of Texas occurred in patients who resided within 50 miles of a TSA center. Increasing volume seems to reflect concentration of care into HV-IP and OP centers. Strategies to improve access to TSA care for underserved areas should be considered.

LEVEL OF EVIDENCE

Level II.

Differences in 30-day outcomes between inpatient and outpatient total elbow arthroplasty (TEA)

BACKGROUND

As the health care system in the United States shifts toward value-based care, there has been increased interest in performing total joint arthroplasty in the outpatient setting to optimize costs, outcomes, and patient satisfaction. Several studies have demonstrated success in performing ambulatory total knee and hip arthroplasty. The purpose of this study was to compare short-term outcomes and complications after total elbow arthroplasty (TEA) across the inpatient and outpatient operative settings.

METHODS

The American College of Surgeons National Quality Improvement Program database was queried to identify 575 patients undergoing primary TEA using the Current Procedural Terminology code 24363. Of this sample, 458 were inpatient and 117 were outpatient procedures. Propensity score matching using a 3:1 inpatient-to-outpatient ratio was performed to account for baseline differences in several variables-age, sex, body mass index class, American Society of Anesthesiologists class, and various comorbidities-between the inpatient and outpatient groups. After matching, the rates of various short-term outcomes and complications were compared between the inpatient and outpatient groups.

RESULTS

Inpatient TEA was associated with a higher rate of complications relative to outpatient TEA, including non-home discharge (14.9% vs. 7.5%, P = .05), unplanned hospital readmission (7.4% vs. 0.9%, P = .01), surgical complications (7.6% vs. 2.6%, P = .04), and medical complications (3.6% vs. 0.0%, P = .04).

CONCLUSION

Outpatient TEA has a lower short-term complication rate than inpatient TEA. Outpatient TEA should be considered for patients for whom such a discharge pathway is feasible. Future research should focus on risk stratification of patients and specific criteria for deciding when to pursue outpatient TEA.

Routine postoperative laboratory tests are unnecessary after primary reverse shoulder arthroplasty

BACKGROUND

Obtaining postoperative laboratory studies after primary reverse shoulder arthroplasty (RSA) is a common practice. However, justification of this practice remains unclear. This study assesses the utility of routine postoperative laboratory studies in RSA.

METHODS

The electronic medical records of 369 patients who underwent RSA over 10 years were retrospectively reviewed. A total of 213 patients qualified for analysis. Primary outcomes were intervention related to abnormal laboratory values, length of stay, and 90-day emergency department visits/readmissions. Multivariate logistic regression analysis was performed to identify risk factors associated with abnormal laboratory values and postoperative visits/readmissions.

RESULTS

Of 213 patients analyzed, 188 (88.7%) had abnormal postoperative laboratory values: 69% had an abnormal hemoglobin (Hgb) or hematocrit level, but only 12% underwent interventions. Lower preoperative Hgb was a significant predictor of receiving a transfusion. A significant association existed between abnormal postoperative electrolyte and creatinine levels with lower body mass index (BMI) and higher Charlson Comorbidity Index (CCI). Only 4 patients (1.8%) received non-transfusion related intervention. Emergency department visits were not statistically different between patients with positive or negative laboratory tests (P = .73).

CONCLUSION

Because 87.3% of laboratory studies did not influence patient management, we recommend against routine testing for primary RSA. This study demonstrates that the practice of obtaining routine postoperative laboratory studies is not justified. We recommend selectively obtaining a postoperative basic metabolic profile in patients with increased American Society of Anesthesiologists classification and/or CCI with a lower BMI. We also recommend selectively ordering postoperative complete blood count in patients with a lower preoperative Hgb.

Outpatient vs. inpatient reverse total shoulder arthroplasty: outcomes and complications

BACKGROUND

Reverse total shoulder arthroplasty (RTSA) is an effective treatment option for many shoulder conditions. Historically, this surgical procedure was performed on an inpatient basis. There has been a recent trend to perform RTSA on an outpatient basis in proper candidates.

METHODS

All patients who underwent outpatient RTSA performed by a single surgeon between 2015 and 2017 were included. Demographic information and clinical outcome scores (American Shoulder and Elbow Surgeons, visual analog scale, and Single Assessment Numeric Evaluation scores), as well as data on complications, readmission, and revision surgery, were recorded. This group of patients was then compared with a cohort of patients who underwent RTSA in the inpatient setting during the same period.

RESULTS

Overall, 241 patients (average age, 68.9 years; 52.3% female patients) underwent outpatient RTSA and were included. Patients who underwent outpatient RTSA showed significant improvements in all clinical outcome scores at both 1 and 2 year postoperatively (all P < .0001). The control group of patients who underwent RTSA as inpatients consisted of 373 patients (average age, 72 years; 66% female patients). Significantly more controls had diabetes (P = .007), and controls had a higher body mass index (P = .022). No significant differences existed in improvements in clinical outcome scores between the inpatient and outpatient groups. Complication rates were significantly lower for outpatient cases than for inpatient controls (7.0% vs. 12.7%, P = .023).

CONCLUSION

RTSA performed in an outpatient setting is a safe and reliable procedure that provides significant improvements in clinical outcome scores with fewer complications compared with inpatient RTSA.

Surgeon charges and reimbursements are declining compared with hospital payments for shoulder arthroplasty

BACKGROUND

The relationship between surgeon and hospital charges and payments for total shoulder arthroplasty (TSA) has not been well examined. The goal of this study was to report trends and variation in hospital charges and payments compared with surgeon charges and payments for TSA.

METHODS

The 5% Medicare sample was used to capture hospital and surgeon charges and payments for TSA from 2005 to 2014. Two values were calculated: (1) the charge multiplier (CM), which is the ratio of hospital to surgeon charges, and (2) the payment multiplier (PM), which is the ratio of hospital to surgeon payments. The year-to-year variation and regional trends in patient demographic characteristics, Charlson Comorbidity Index, length of stay (LOS), CM, and PM were evaluated.

RESULTS

The study included 10,563 patients. Per-patient hospital charges increased from $33,836 to $67,177 (99.9% increase), whereas surgeon charges increased from $4284 to $4674 (9.1% increase) (the CM increased from 7.9 to 14.4, P < .0001). Hospital payments increased from $8758 to $14,167 (61.8%), whereas surgeon payments decreased from $1028 to $884 and the PM increased from 8.5 to 16.0 (P < .0001). The LOS decreased significantly (P < .0001), whereas the Charlson Comorbidity Index remained stable. Both the CM (r² = 0.931) and PM (r² = 0.9101) were strongly negatively associated with the LOS.

CONCLUSIONS

Hospital charges and payments relative to surgeon charges and payments have increased substantially for TSA despite stable patient complexity and a decreasing LOS. These results encourage the need for future studies with detailed cost analyses to identify the reasons for hospital and surgeon financial malalignment.

Same-day discharge is not inferior to longer length of in-hospital stay for 90-day readmissions following shoulder arthroplasty

BACKGROUND

Shoulder arthroplasty is a common orthopedic procedure, performed historically in the inpatient setting. However, interest in same-day discharge has increased. We sought to evaluate 90-day readmission, 90-day emergency department (ED) visit, 90-day deep infection, 90-day venous thromboembolism (VTE), and 1-year mortality after same-day shoulder arthroplasty compared with an inpatient stay.

METHODS

We conducted a retrospective cohort study using data from an integrated health care system's Shoulder Arthroplasty Registry. A total of 6503 elective primary unilateral total shoulder and reverse total shoulder arthroplasties performed between 2005 and 2016 were included; 405 (6%) had same-day discharge. The likelihood of 90-day events, including readmission, ED visit, deep infection, and VTE, and 1-year mortality after same-day discharge was compared with 1- to 4-night inpatient stay using generalized estimating equations with noninferiority testing, adjusting for age, sex, body mass index, race, American Society of Anesthesiologists classification, select comorbidities, osteoarthritis, anesthesia type, procedure type, and surgeon effect.

RESULTS

We failed to observe a difference between same-day discharge and 1- to 4-night stay in terms of 90-day readmission, 90-day ED visit, and 1-year mortality. Same-day discharge was not inferior to 1- to 4-night stay regarding 90-day readmission, but we did not have evidence to support noninferiority for 90-day ED visits or 1-year mortality. Ninety-day deep infections and VTE were too infrequent for adjusted analysis.

CONCLUSIONS

We found same-day shoulder arthroplasty not to be inferior to an inpatient stay for 90-day readmission. Future investigation into the reasons for readmission and ED visit after same-day shoulder arthroplasty and interventions to mitigate these adverse events is needed.

The transition of total elbow arthroplasty into the outpatient theater

Background

Outpatient total joint arthroplasty is increasing in frequency as reimbursement models change. Potential benefits include same-day surgery for patients and decreased exposure to nosocomial pathogens. This study aims to determine if total elbow arthroplasty (TEA) is also trending toward an outpatient setting, and if there is any impact on complication rates as a result.

Methods

A retrospective chart review of the American College of Surgeons National Surgical Quality Improvement Program was performed. Specifically, the database was queried for all patients with CPT code 24363 from 2010-2017. The percentage of TEAs performed each year as an outpatient was trended from 2010-2017. Additionally, the complication rate between the inpatient and outpatient cohorts was compared.

Results

A total of 524 TEAs were analyzed. Of these, 111 procedures (21.2%) were performed as an outpatient. There was a statistically significant increase in the percentage of outpatient TEAs from 2010-2017 (P = .0016). In 2010, 2.4% of TEAs were outpatient, compared with 34.5% in 2017. The total complication rate trended toward being lower in the outpatient group, but this difference was not statistically significant (P = .08).

Conclusions

There is a significant trend toward TEA being performed as an outpatient procedure, with more than one-third currently being performed in this manner. In our study, there was no difference in the complication rate between inpatient and outpatient TEAs; in fact, outpatient TEAs trended toward having a lower complication rate than inpatient TEAs. Taken together, the outpatient setting comprises an ever-increasing segment of TEA without an increase in morbidity to patients.

Quantification of patient-level costs in outpatient total shoulder arthroplasty

BACKGROUND

Patient-level costs of inpatient and outpatient total shoulder arthroplasty (TSA) irrespective of payer status are seldom reported. The purpose of this study was to compare patient-level costs of primary elective TSA between inpatient and outpatient surgery centers.

METHODS

By use of the Texas Health Care Information Collection database, inpatient and outpatient TSAs performed between 2010 and 2015 were identified according to billing codes. Patient-level costs (total charges and itemized charges) were analyzed according to type of surgery center (inpatient vs outpatient) and inpatient volume (high volume vs low volume). Statistical comparisons were performed using 1-way analysis of variance and 2-sample independent t tests. Mixed-model analysis of variance was used to compare the rate of cost change between inpatient and outpatient TSAs from 2010-2015. P < .05 represented statistical significance.

RESULTS

A total of 21,331 inpatient TSAs and 1542 outpatient TSAs were performed from 2010-2015 in the state of Texas. Inpatient TSA costs were significantly higher than outpatient TSA costs ($76,109 [standard deviation (SD), $48,981] vs $22,907 [SD, $13,599]; P < .001). After exclusion of inpatient-specific charges, inpatient TSA remained 41.1% more expensive than outpatient TSA ($32,330 [SD, $24,221] vs $22,907 [SD, $13,599]; P < .0001). High-volume inpatient TSA was less expensive than low-volume inpatient TSA; however, high-volume inpatient TSA remained 33.4% more costly than outpatient TSA even after exclusion of inpatient-specific charges ($30,579 [SD, $23,233] vs $22,907 [SD, $13,599]; P < .0001).

CONCLUSIONS

In the state of Texas, the patient-level costs of primary elective inpatient TSA were significantly higher than those of the equivalent outpatient procedure. This difference persisted after exclusion of low-volume inpatient TSA centers and inpatient-specific ancillary charges.